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Standing Committee on Health



Monday, February 12, 2018

[Recorded by Electronic Apparatus]



     We'll call our meeting to order. Welcome, everybody, to the 89th meeting of the Standing Committee on Health.
    Today, we're starting a new study on Bill S-5, an act to amend the Tobacco Act and the Non-smokers' Health Act and to make consequential amendments to other acts.
    It looks as though our witnesses today have brought lots of homework for us. From Physicians for a Smoke-Free Canada, we have Neil Collishaw, research director. From the Canadian Cancer Society, we have Rob Cunningham, senior policy analyst. From the Heart and Stroke Foundation of Canada, we have Lesley James, senior manager, health policy. As an individual, we have Dr. Gaston Ostiguy, chest physician, associate professor and past director of the smoking cessation clinic, McGill University.
     Welcome, everyone. We'll ask each of you to make an opening statement of no more than 10 minutes and then we'll go to questions. We'll start with Physicians for a Smoke-Free Canada.


    Honourable members, thank you for your invitation to present our views on Bill S-5, An Act to amend the Tobacco Act and the Non-smokers’ Health Act and to make consequential amendments to other Acts.
    I am the research director at Physicians for a Smoke-Free Canada. Although I'm not a doctor, I have been working for 35 years in the area of tobacco control. I worked at Health Canada in the 1980s and at the World Health Organization in the 1990s.


     Bill S-5 will legitimize what is currently a grey market for vaping products. It will give some clarification that facilitates the introduction of plain packaging and will make a small number of other important advances for tobacco control. Sadly, however, the bill, as currently drafted, contains unnecessary risks to public health. If these flaws are not corrected, we predict that the bill will create more problems than it solves.
    The fundamental flaw in the bill is that it opens the door too wide for the promotion of vaping products. One consequence of legalizing vaping products is whether it will invite tobacco companies into the Canadian market with new vaping products. They do not participate now in the grey market.
    Royal assent on this bill will be the starting gun for the race to sell as many of these products as they can, using every marketing tool that this law will hand them. The bill hands them too many such tools. As currently drafted, it will allow them to advertise on television, radio, billboards and retail outlets, social media, direct mail, text messaging, contests, and giveaways. Once again, girls in skimpy outfits could be sent into bars to offer samples to patrons. We have seen the same companies use these same tools to recruit and addict previous generations to nicotine.
    Our recommendation for minimizing this risk is simple: restrict advertising for vaping products the same way it is restricted for tobacco, which, you will remember from your review of Bill C-45, is also under the same types of restrictions that are in place for cannabis. Permit only information and brand advertising advertisements and allow that only in a very few places. Even if the marketing rules are the same, vaping products will still enjoy a marketplace advantage over tobacco products as they will be sold in branded packages with lesser health warnings and without taxes. We are not alone in making this recommendation. Most major health organizations also suggest that vaping products be subject to similar restrictions.
    In response to these concerns, the Senate adopted the amendments proposed by the health department to give the government regulatory authority to curb advertising of vaping products in case things went wrong. A few months later Health Canada issued a consultation paper on the types of regulations it was considering, and these were a throwback. They were very similar to those that the tobacco industry used to govern itself in place for cigarettes in the 1960s and 1970s.
    Restricting television advertising to certain times of day, billboards to certain distances from schools are not good enough, and we know this from bitter experience. No one should be encouraging a consumer product that has a better than 30% chance of addicting people to lifelong use. Regulations cannot put the advertising genie back in the bottle. We need to restrict advertising for vaping products now, not later; and we need to do it strongly, not weakly.
    If this bill passes as currently drafted, Canada will be virtually alone in allowing such liberalized rules for promoting vaping products. Most OECD countries that allow vaping products to be sold apply similar advertising restrictions to those that exist for tobacco. Only the U.S.A. allows largely unrestricted advertising for vaping products, and what has this meant for young Americans? Well, I think the title of the December 2016 press release from the U.S. Surgeon General is the answer: “Surgeon General Reports Youth and Young Adult E-Cigarette Use Poses a Public Health Threat”.


     Now I turn to another flaw in BillS-5, one that could be described as a serious omission.
    While opening the door to vaping products and their advertising, Bill S-5 fails to start closing the door to other tobacco products. Bill S-5 legalizes vaping products in the hope that they will offer some reduction from the harm that tobacco causes. It's a nice hope and I hope it comes true, but it's still only a hope. To guarantee that harm will be reduced, we need a plan to get rid of the conventional cigarette.
    A few months ago the U.S. pushed forward with its vision of how to ensure that the benefits of less harmful forms of nicotine use were accompanied by a reduction in the use of the most harmful forms. The U.S. Food and Drug Administration announced a comprehensive harm reduction framework in July 2017 in which they plan to reduce the amount of nicotine in conventional cigarettes as a way of shifting smokers to less harmful forms. Because of particularities of American law and regulation, the FDA is constrained on how it can regulate cigarettes and they have chosen nicotine reduction because basically the law doesn't allow them to have any other options. But in Canada we do—you do, as legislators.
    We can follow and improve on the American lead by creating a harm reduction framework that aims to reduce the supply and demand for cigarettes by using a range of approaches. These might include cap and trade programs, financial incentives, performance requirements, and other modern regulatory tools. The government has set a goal of achieving less than 5% tobacco use prevalence by 2035, “less than 5 by 35”, but so far it seems to be less of a plan and more of a slogan. However, there is now an opportunity through Bill S-5 to establish a harm reduction framework that will ensure that legalizing vaping helps reduce smoking.
    Here are some key changes that we are proposing in very much summary form: expand the purpose of the act to include reducing the burden of disease, preventing addition to nicotine, and achieving the minister's goal of less than 5 by 35; expand the scope of the act once again to establish regulatory authority over new heat-not-burn products as well as other new tobacco products that may be introduced in the future; and impose new requirements and obligations on the tobacco industry.
    We have prepared detailed suggestions for how these changes could be introduced during clause-by-clause review of the bill, and I will be happy to share our suggestions with you later on.
    This committee can greatly assist in achieving the goal of less than 5 by 35. Don't allow Bill S-5 to be passed without the safeguards needed to protect young people and others from tobacco and nicotine industry marketing. Make sure that Bill S-5 is a step towards ending the sale of combustible tobacco products and not a way to recruit future smokers.
    Thank you for your attention.


    Thank you very much.
    Now we go to the Canadian Cancer Society. Mr. Cunningham.
     Mr. Chair, committee members, my name is Rob Cunningham, a lawyer and senior policy analyst for the Canadian Cancer Society.


    Thank you for the opportunity to appear before you today.


     At the outset, we acknowledge the federal government and Health Minister Hon. Petitpas Taylor for their support in advancing tobacco control. We also acknowledge all parties in supporting Bill S-5 at second reading, and the role of all parties over decades to contribute to advancing tobacco control in Canada.
    We support Bill S-5 and have a number of recommended amendments to improve the bill.
    First, I will speak to plain and standardized packaging. This is a key tobacco control measure, including to protect youth. Canada will join the eight countries that have finalized plain packaging requirements: Australia, United Kingdom, France, Ireland, Norway, New Zealand, Hungary, and Slovenia, and the many more in progress.
    This binder that has been distributed to you includes an international review of where things are at.
    Plain packaging advances several objectives: reducing tobacco product appeal, curbing package deception, ending promotional aspects of packaging, improving health warning effectiveness, and reducing tobacco use. The package is the most important type of tobacco advertising that remains in Canada today. Tobacco is addictive and lethal and should not be sold in packages to be made more attractive, period.
     Imperial Tobacco has stated there is no evidence to support plain packaging. In fact, the evidence is overwhelming. Beside me is an extensive 13-volume evidentiary compilation submitted to this committee. It is available for your review and consideration. The compilation contains abundant studies worldwide that provide compelling evidence that plain packaging would be effective. There are more than 150 studies and reports and other evidentiary items specifically on package promotion and plain packaging, not to mention a vast number on package warnings and other related packaging aspects. Distributed to you separately is a table of contents.
    Of course plain packaging would be effective. Why else would the tobacco industry be so opposed?
    Implementation of plain packaging in Australia has been a success, but the tobacco industry claims that plain packaging in Australia has been a failure, claims echoed by Sinclair Davidson, who will testify later today. Mr. Davidson is a senior research fellow with Australia's Institute of Public Affairs, an organization that has received tobacco industry funding. The real benefit of plain packaging will be seen over 20 years but the initial years are already encouraging. If I can invite members of the committee to turn to tab 4 in this binder, you will see a graph with respect to the trend in smoking prevalence in Australia. Plain packaging was implemented in 2012, and you see a decline in smoking prevalence after. It's not the case that smoking declines have stalled.
    If we turn to the next page, this is for 18- and 19-year-olds. Again, we see a decline in smoking prevalence. This is the national drug strategy household survey. The sample size for youth is smaller, but the next page has a much bigger sample size; current smoking in 16- and 17-year-olds in Australia, and there's a decline. When smoking rates get low, even a couple of percentage points are very important in terms of potential health impact.
    There are other graphs that follow different sample size to the extent that they're reliable, and there's caution, but they're encouraging.
    In France, the tobacco industry points to a decline in cigarette sales of 0.7% in the 12 months following implementation of plain packaging on January 1, 2017 to say that plain packaging is not working. However, there was also a decline of 5.1 % in roll-your-own tobacco, an important category in France. When considering population growth, the per capita declines are about 2% and 6%. Those numbers do not take into account inventory movements and changes in contraband levels, which can distort things. Just prior to implementation, retailers would have decreased their purchases to get rid of old stock and not to be stuck with things that would be redundant. After January 1, they had to replenish their inventory, so that distorts things.
    The French government has strongly supported plain packaging and in 2015 even hosted a 10-country ministerial meeting to promote plain packaging with ministers of health from other governments.
     One claim that has been raised is that, with plain packaging, it will take more time for a store employee to retrieve a package for a customer. This has not been the case in Australia, where many retailers simply place brands in alphabetical order. Studies in Australia found that there was actually a decrease in the time it took to retrieve a package.
     Regarding contraband, industry claims should be disregarded as without merit for numerous reasons. Tab 3 of the binder responds to their claims. Keep in mind that the three major tobacco companies in Canada in 2008 and 2010 were convicted of contraband and paid fines and civil settlements of $1.7 billion.
    The only reports cited to support the claim that plain packaging increases contraband are funded by the tobacco industry. KPMG, author of various reports, was forced to take the unusual step of writing to the British health minister denying that its report indicated that plain packaging increased contraband, as the industry has cited. The report found no counterfeit products, none, packaged for the Australian market. The total volume of all contraband in 2016 of 2.3 million kilograms was less than the 2.4 million kilograms in 2010 prior to plain packaging.
     Imperial Tobacco argues that taking the brand name and logo off cigarettes will cause contraband. This is not the case. In part, companies will be allowed to place an alphanumeric indicator on cigarettes unique to each brand, as is done in Australia. There should also be a mandatory marking, something that Ms. Gladu and other members of Parliament raised during second reading debate. Such a marking would provide an indication as to what is intended for legitimate sale in Canada and would assist responding to contraband concerns. The best mandatory marking would be a health warning, a measure supported by research.
    An amendment to the bill should provide regulatory authority to allow health warnings directly on tobacco products themselves, in addition to packages, just as the bill currently does for vaping products.
    Our recommended amendments to the bill are included at tab 1 of the binder.
    A further amendment should provide regulatory authority that some or all of the provisions of the act in the future could apply to herbal products for smoking, including herbal water pipe products. Water pipe use, hookah, is on the increase among youth and needs a response. An amendment should modify the process to adopt regulations under the Tobacco Act. It should no longer be necessary to submit regulations to the House of Commons for approval. Almost no other federal legislation has such a requirement, which inhibits effective and rapid responses that are essential when dealing with an epidemic.
    Regarding e-cigarettes, we recognize that e-cigarettes are less harmful than conventional cigarettes, and we support the changed regulatory status in S-5. Through Bill S-5, the government is making e-cigarettes available as a less harmful product to smokers unable to quit. At the same time, the government recognizes that there are potential negative risks. Legislation is needed to deal with those potential risks, such as youth use, as well as marketing tactics that would discourage cessation where that would appeal to ex-smokers and non-smokers. Many of the bill's e-cigarette advertising restrictions are weak compared to other jurisdictions.


     An amendment should ban all lifestyle advertising. Examples could include tropical beaches, sports cars, and glasses of wine by a romantic sunset—examples allowed by this bill. The Canadian Vaping Association, in Senate committee testimony, supported a lifestyle ban.
    An amendment should clearly specify that the only advertising allowed is information advertising or brand preference advertising. This is reasonable. This is in fact the government's stated intent, but the intent is not reflected in the bill's current wording. Again, the Canadian Vaping Association testified that it wanted advertising limited to information advertising.
    An amendment should further curtail sales promotions, such as e-cigarette purchases giving a chance to win a free vacation or tickets to a rock concert. Again these are lifestyle associations.
    An amendment should restrict the location of permitted advertising and thus reduce youth exposure, though still permitting advertising to adult audiences. At present there is no restriction in the bill whatsoever on location; it's weaker than for tobacco or cannabis. Advertising is allowed on television, public transit, bus shelters, billboards, comic books—virtually everywhere.
    Other countries, such as New Zealand, that are legalizing e-cigarettes with nicotine will ban e-cigarette advertising while allowing some at retail, in a way that matches provisions for tobacco.
    What we have in Bill S-5 is provisions so weak that they're comparable to the 1964 Canadian tobacco industry voluntary code. They are very weak, even when you consider proposed regulations that the government has released for consultation.
    Even with the proposed amendments on e-cigarette promotion, federal and provincial legislation would still allow retail displays and the provision of product information in specialty vape shops as well as in other specified locations.
    We urge support for Bill S-5 and our proposed amendments. Bill S-5 is a critical component to a renewed and strengthened federal tobacco control strategy.
    Before concluding, I would like to comment on the claim by Rothmans, Benson & Hedges that they want to end smoking and stop cigarette sales. This is a public relations claim; it is not believable. Why are they not supporting plain packaging for cigarettes, if that is their objective? Why are they funding convenience store associations to talk about contraband and to oppose tax increases for cigarettes?
    Tab 5 of your binder shows the global campaign for Marlboro with lifestyle advertising—the “Be Marlboro” campaign. This is not a company that's sincere about ending cigarette sales, when they have advertising like that. This is a company that today, on packages of Canadian Classics, has a mountain lake scene that looks like Banff or Lake Louise. That's a lifestyle association. It's an example of why we need plain packaging.
    They sell Benson & Hedges super slim cigarettes, which are very appealing to young girls and women. Those should be banned.
    We have other companies.... For example, this is a company that has marshmallows over a campfire; this is Pall Mall. It's an association with lifestyle that is very appealing, and plain packaging would deal with it.
    Just as a final example, because there are so many of them, this example is from Rothmans, Benson & Hedges. They have a package of cigarettes, but with a sleeve that has advertising. That's how they get around restrictions on bans on billboards.
    This is an opportunity for us to implement plain packaging.
    We express our appreciation to all committee members for the opportunity to appear.
    Thank you.


    Thank you very much.
    Now we will go to the Heart and Stroke Foundation, Ms. Lesley James.
     Good afternoon, Mr. Chair, and members of the committee. I'm Lesley James, senior manager of health policy at the Heart and Stroke Foundation of Canada. I'm also a doctoral researcher.
    It's an honour to speak to you today about Bill S-5, a key piece of legislation in achieving Heart and Stroke's vision of a Canada free of commercial tobacco use.
    Your committee will hear from many of our health coalition partners and tobacco control experts on this subject. Our common agreement is that we support aspects of Bill S-5 as related to plain and standardized packaging but have significant concerns with the bill's permissiveness around the wide-scale marketing of e-cigarettes. As such, we recommend amendments.
    Bill S-5 represents an important step to strengthen tobacco control. It aims to protect the health of our children and youth from the industry tactics that target young Canadians and hook them to addictive and harmful products.
    While Bill S-5 in its current form recognizes the power of tobacco marketing in appealing to young Canadians, it fails to protect that same vulnerable group as well as non-smokers from persuasive, e-cigarette advertising. In this regard, Bill S-5 contains a fundamental flaw, and we hope to see amendments made to address this disconnect between marketing restrictions.
    The federal government has committed to a goal of less than 5% tobacco use by 2035. Despite efforts to reduce tobacco use in Canada, smoking rates remain unacceptably high at 17%. We support the 5% target and strongly believe that Bill S-5 is a key piece of legislation to achieve this target.
    Getting to 5% is important because tobacco use remains the leading cause of premature death in Canada, killing over 45,000 Canadians each year; that's 120 of us every day. Nearly one in five deaths in Canada can be attributed to tobacco use. We have much work ahead of us, especially as it relates to young Canadians.
    Smoking rates are greatest among young adults, aged 20 to 24, at 18.5%. Sadly, almost 10% of 15- to 19-year-olds in Canada identify as current smokers. We know that most smokers start as teenagers, but 20% of Canadians try their first cigarette as young adults.
    How do we address this issue and reduce tobacco use among all Canadians, with a particular focus on youth and young adults? The answer is plain and simple. Heart and Stroke strongly encourages and supports the adoption and expedited implementation of plain and standardized tobacco packaging. Our organization has been urging for the adoption of this policy measure for decades, and I would like to show you why it's so important.
    I have examples of packs sold in Canada. This is a pack targeted towards young men. We call it the hipster pack. It's trendy. It's kind of rustic looking. These ones are targeted towards young females. They're meant to look like cosmetics packages. The lipstick that I bought last week looks just like this. You can see that the product inside is equally as appealing as the outside. It's appealing and glamourous.
    As a woman who understands and recognizes that these products shrewdly appeal to gender-specific beauty norms and ideals, I want to emphasize that these gender-oriented tactics, preying upon young and vulnerable women, are offensive, demeaning, and need to be stopped.
    The use of the words “slim” and “vogue” along with the delicate but sparkly cigarette also demonstrate that the product itself should be mandated to be unappealing. This would entail banning slim cigarettes and would provide an opportunity to use the product itself for health messages.
    As such, we ask for an amendment in this bill providing the regulatory authority to require health messaging on the product itself. This is already the case for e-cigarettes in this bill. Messages like “tobacco kills” or the promotion of cessation programs on each cigarette would be highly effective in dissuading use and increasing quit attempts.
    Plain packaging has been endorsed by the World Health Organization and adopted in many countries. Evidence indicates it has a variety of benefits including accelerated declines in tobacco use, curbing deceptive marketing messages, increasing the visibility and effectiveness of health warnings, reducing the appeal of tobacco among youth, and increasing smoking cessation attempts.
    After the policy's implementation in Australia, positive image associations across all tobacco brands fell, and the greatest decline was seen among adolescent smokers.


     Concerns about contraband in relation to plain packaging are inaccurate, overstated, and exaggerated by the tobacco industry. Contraband concerns are often used as an industry narrative to stall tobacco control policies.
    We applaud all parliamentarians for forging ahead with plain packaging and recognizing the tactics used by the tobacco industry and its front groups. Plain packaging is a powerful policy measure fully endorsed by Heart and Stroke and hundreds of health experts in Canada.
    With regard to vaping products, Heart and Stroke's position on e-cigarettes has evolved over time with advances in research, and while the evidence regarding e-cigarettes continues to grow, there is still much left unknown. We continue to strive for a balance between potential risks and benefits and to that end it is important that regulations ensure product safety and protect Canadians against potential harm.
    Experts agree that complete tobacco cessation over the long term rather than reducing the number of cigarettes smoked per day is the most effective way to reduce risk for disease and premature death. Heart and Stroke encourages people in Canada to strive for complete cessation as the best means of reducing tobacco-related illness.
    We recommend Canadians use cessation tools like nicotine replacement therapy, quit medications, and counselling. Some Canadians may find cessation benefits for reductions in tobacco consumption from the use of vaping products, but in Canada, as elsewhere in the world, dual use of both e-cigarettes and tobacco is common, which puts into question the public health benefit of these devices.
    Heart and Stroke agrees that e-cigarettes are less harmful than combustible tobacco, and for this reason we support increased access to e-cigarettes for adults. However, e-cigarettes are not without risk. Claims made by researchers that quantify the difference in associated harm between e-cigarettes and combustible tobacco are based on faulty methods and draw inappropriate conclusions.
    We have known for years that e-cigarettes are appealing to Canadian youth. A study found that 18% of non-tobacco-using Canadian high school students had tried e-cigarettes and another 31% were interested in trying them. Current use of e-cigarettes among 15- to 19-year-olds has more than doubled in the past few years. Studies also show that more teens are using e-cigarettes, seeing them as cool and fun, and research in Canada shows a link between e-cigarette use among youth and later tobacco use.
    We want to ensure that e-cigarettes do not result in nicotine addiction and tobacco use. It is essential that young Canadians be protected from marketing exposure aiming to increase the use of these products. Not only are there potential harms with the liquid constituents of vaping devices but we need to protect non-smokers and youth from nicotine, which will become legal and more readily available once Bill S-5 is passed. Nicotine is a highly addictive drug that increases blood pressure, makes your heart work harder, and can cause blood clots.
    It is essential that Bill S-5 be amended to further restrict the marketing of e-cigarettes in Canada. In its current state, wide-scope marketing would be permitted for advertisements everywhere and anywhere, television, online, video and advergames, newspapers, magazines, billboards, public transit, social media, and the list goes on.
    Of great concern is that marketing can happen in bars and night clubs, places where young people often congregate and are under the influence of alcohol. This can make them more susceptible to marketing messages and create opportunities for young Canadians to experiment with e-cigarettes. There is no need for marketing in places frequented by young people or the widespread marketing of vaping products to the general public. The only group that should be exposed to the marketing of these products are current tobacco smokers.
    The proposed ban on lifestyle advertising will not be strong enough to protect young people from the multi-billion dollar marketing machinery of the industry. As such, we ask that Bill S-5 be amended in relation to vaping products to include strengthened restrictions on e-cigarette advertising to align with the restrictions in the Tobacco Act and proposed cannabis act and the removal of the provision that allows lifestyle advertising in bars and adult publications.
    Heart and Stroke also formally endorses the recommendations proposed by the Canadian Cancer Society.
    To conclude, Heart and Stroke strongly supports the proposed legislation related to plain and standardized packaging and is recommending amendments to increase the impact of the bill. We urge that this committee make Bill S-5 a key piece of legislation that truly protects our kids and prevents uptake by non-smokers in further restricting e-cigarette marketing.


     In adopting these amendments, Bill S-5 will become a strong and powerful piece of legislation to drive down tobacco control and put the health of Canadians first.
    Thank you for your time.
    Thank you.
    Now we go to Dr. Ostiguy. You have 10 minutes.
     Thank you very much, Mr. Chairman, and members of the committee. I thank you for allowing me to speak to you today. I'm grateful for the invitation.
    I've been directing a smoking cessation clinic for quite a few years. My experience is dealing with ill and very ill smokers. This is more or less the sense of my intervention.
    It is rather naive to think that all smokers want to stop smoking and are able to stop smoking. Nowadays even the best clinical studies usually have a success rate of less than 30% abstinence of one year. Approximately one in three smokers in the United Kingdom currently attempts to quit each year but only about one in six of those who try to quit remains abstinent for more than a few weeks or months. It is about 5.5% altogether. In Canada, 66% will attempt to quit in the next six months.
    Cigarettes are the most addictive tobacco product. As it is well recognized, if it is the most addictive tobacco product, it might not be that easy to stop smoking. It takes more than just willpower.
    We know very well that tobacco smoking has very dreadful consequences on health, both for the smoker and for the ones who are exposed to second-hand smoke. Smoking tobacco kills, but nicotine does not. Nicotine does not cause cancer, does not cause cardiovascular disease, and does not cause pulmonary disease—COPD, for example. But nicotine creates a dependence. As a chest physician, I've seen enough lung cancer and cases of COPD, asthma, and chronic bronchitis to know that this is a dreadful consequence of smoking. Lung cancer and COPD represent our daily bread in chest medicine. Fifty per cent of smokers will die from a tobacco-related disease. Smokers will die eight to 10 years earlier than non-smokers. Smokers who stop smoking before the age of 35 have a longevity similar to non-smokers. Smokers who quit by the age of 35 can live as long as non-smokers, both men and women. Very little attention is paid to this group of smokers.
    I don't have the time to talk about all the illnesses related to tobacco smoking, so I'll concentrate on cancer. Smoking is involved in the etiology of at least 14 different cancers. For some of these it is the main cause, like lung cancer. E-cigarette vape might contain some carcinogenic substances but it is less than 1% of the threshold limit value in the workplace and up to 450 times lower than in cigarette smoke.
     Swedish people have used snus for many years, since the beginning of the 20th century. They have the lowest lung cancer rate in the world. It is lower than the United States and lower than Norway. It represents an important fall in the number of deaths by cardiac attack, a fall of 22% in men between 1987 and 1995. It has a low rate of buccal cancer, which keeps on falling in spite of increased use of snus.
    Despite controversy, it is clear that e-cigarettes are far less hazardous than tobacco—95% less. I hope that people had a chance to look at the fourth Public Health England report confirming this conclusion, which was issued last week. Smokers smoke primarily for the nicotine, but die primarily from the tar, the combustion of tobacco.
    If you look at the number of illnesses related to tobacco smoking, and on the other side, at the addiction that might be created by nicotine, you see that the question becomes, for nicotine-addicted tobacco smokers, is it ethically and morally correct to discourage them from using a 95% less harmful nicotine delivery system?


     In conclusion, e-cigarettes can save many thousands of lives. You have the numbers that have been figured out by Great Britain, U.S.A., and China, but they have to be regulated. They must not be advertised, like my predecessors have spoken about, but their availability must not be made more difficult than buying tobacco cigarettes.
    Dr. Polosa just recently published a study showing that it is very important that the addicted smoker who wants to switch to electronic cigarettes be coached and shown how to use them. In my experience, when older people buy electronic cigarettes, they don't use them properly.
    Thank you very much for your attention.
    Thank you all for your presentations.
    Now we'll go to our question period. Each member will start with seven minutes, starting with Mr. Oliver.
    Thank you very much for your testimony, the research, and leadership you've been showing on the issues of smoking and smoking cessation in Canada over the years.
    To me, there are two issues we are dealing with here. One is stopping non-users, in particular youth, from becoming addicted to nicotine, and the numbers are still quite alarming. I read just recently that there are about 100,000 new daily smokers per year in Canada, and something like 82% of people start smoking at the age of 18 or younger, so there is clearly an issue of stopping young people and non-users from getting the habit.
    The second grouping is those who are addicted to nicotine, and trying to move them to a less harmful form, given that the evidence isn't quite clear yet, but there is a fair bit of it, and/or helping them quit.
    My first question deals with that second population, people who are addicted and want to move to a less dangerous or harmful form. I had somebody in from the tobacco industry to meet with me to talk about their view, and that was fine. They were sort of doing their rounds. The concern they raised was on proposed section 20.1 where it says:
No person shall promote a tobacco product, including by means of the packaging,
(a) in a manner that could cause a person to believe that the product or its emissions are less harmful than other tobacco products or their emissions...
     and the example was heat-not-burn consumption.
    I'd like to get your reaction to that first of all. If the tobacco industry does believe they have found a safer way to consume nicotine, they wouldn't be able to advertise or promote that on packaging. Do you agree with them or disagree with them? I'd like to hear your perspectives on that one, from all of you.


    The international standard is for a complete ban on tobacco advertising. That's in the WHO framework convention on tobacco control. We support that.
    Canada does not have a ban. We have restrictions, but many countries do have a ban, including where e-cigarettes and tobacco products are sold. That product will be more harmful than e-cigarettes. E-cigarettes will be able to be marketed, and Health Canada, with an amendment at the Senate committee—it was already in the bill but there's a clarifying amendment and a consultation document—is intending to allow certain messages for e-cigarettes with the health aspect.
    We support a total ban of tobacco advertising far stronger than what's in this bill.
    I'd perhaps add another comment. I think you heard from several of us that we want the same or approximately the same level of restriction for e-cigarettes and cigarettes. It's important to realize that tobacco can be advertised through information and brand preference advertising. You don't see much of it, I guess because the tobacco industry isn't proud of the true information about their product, but it might be different for e-cigarettes if they're allowed information advertising and brand preference advertising. Maybe we will see some that's legitimate.
    Speaking more specifically to whether there is a safer way to take in nicotine for those who are addicted, should the industry be able to advertise that?
    You're off on a bit of a different topic there.
    Yes, we're supporting legalization of this bill precisely so that current smokers can legitimately get this product that may possibly offer them a less hazardous way of getting nicotine. The problem is that, while supporting that view, you have to be concerned about the danger of introducing this product as well.
     I understand. Thank you. I'm dealing specifically with proposed section 20.1.
    What we're looking for is the balance.
    Thank you.
    Lesley, do you have any comment on this?
    Again, we support legalization of e-cigarettes with nicotine, to offer Canadians the option. That said, there are better standards and devices available for cessation.
    If we want to target current people addicted to nicotine, as you mentioned, we have a vehicle in the tobacco package itself: a message saying that e-cigarettes are less harmful. That's marketing to the exact audience we want to market to, and nobody else has to see it.
    We thus have the solution right in front of us now.
    Wouldn't proposed section 20.1 make that not possible?
    If it were a Health Canada message, it would be allowed, but the industry wouldn't be able to make that claim.
    Okay, thank you.
    Moving on, then, I think I've heard every single one of you say that Bill S-5 is not strong enough in terms of preventing youth and non-users from picking up the nicotine habit or becoming addicted. Every one of you said that there should be greater advertising restrictions for the e-cigarette vaping products and have it match the....
    Do you have any understanding of why Health Canada wouldn't have adopted that, given that we all agree that nicotine in and of itself is a harmful substance?
    I think it's a matter of getting the balance right. This committee had a study with a report in 2015 with respect to this. It's a new area, and they're trying to get the balance right. We think that the line is drawn in the wrong place, and we'd like to move the line along, with further restrictions.
    I'm certainly with you on that. I have to say categorically that anything we can do to stop new generations and non-users from becoming addicted to nicotine, we should be doing, as a society. It's an incredibly addictive drug. It's in all of our interests to see the addiction to nicotine ended in Canada, if we can get there.
    Doctor, I missed you in the first go around and the second. Do you have any thoughts about advertising, and is Bill S-5 restrictive enough for e-cigarettes and vaping, or do you think we should be doing more?


    I think one of the problems we're facing at the moment is that if you deal with a case of emphysema or a case of throat cancer, and the patient has tried five, six, seven times to stop smoking with all the available tools that exist at the moment and hasn't been able to do so—and this is the sort of clientele we have—then we could suggest to them, “Why don't you try the electronic cigarettes?” They will say, “Well, doctor, why should I use the electronic cigarette? It is as harmful as the tobacco cigarettes.” This is what is publicized; this is the common thinking in the population, so it's very difficult.
    As a matter of fact, in the last few years people were coming to the clinic who had already bought their electronic cigarettes but hadn't started using them because of this confusion that was existing in their minds, and they would ask, what you do you think?
    Of course, this does not prevent us from suggesting to them the approved pharmacotherapy. I mean, you don't treat hypertension with one drug; you treat hypertension with various drugs and treat diabetes with various drugs. Why don't we treat tobacco addiction with various means? The message believed by half the population at the moment—and I feel that this is very sad, and it's true also in Europe and in Great Britain—is that electronic cigarettes are as harmful as tobacco cigarettes. It's very unfortunate.
    Okay, thank you very much.
    Now we go to Ms. Gladu.
    Thanks to all the witnesses for appearing today.
    My first question is for Mr. Cunningham. It's on the subject of contraband. We know that we have a significant problem today in Canada. Across the country, 40% is one of the numbers I've heard, although in Ontario I think it's even higher—60%.
    I just want to confirm that the outside of the plain package still contains the protections designed by Health Canada. I think there were 17 different kinds of technology preventions to keep them from being copied.
    Could you talk a little bit about those and about what to do to the actual cigarettes themselves in terms of the alphanumeric code that we spoke of?
     This is, again, a package from Australia. The brand name still appears, so you're able to tell which brand is which. On the inside, on the cigarette—and companies are allowed to do this—there are letters and numbers that are unique to each brand. That's one way they are allowed, and they do in Australia, to make it a distinctive brand. Health Canada is contemplating that as well.
    In Canada we do have on the package a tax marking. It's like money. It's a unique number for every different package. That will continue. But I think we can enhance that with a marking directly on the cigarette so we can tell what is intended for legitimate sale in Canada and what is not. It will be a bilingual message, and short, ”Every cigarette is doing you damage. Smoking kills”, and a toll-free quit number. You wouldn't have it on exported product. If somebody's in the United States or some other country, and they want to divert something to Canada, it's a different step to have a marking. If it has a marking intended for Canada, and they say it's for the United States, they're going to get caught. If it doesn't have the Canadian marking, it's not. It's a further tool to help enforcement authorities. There's good research to support it as well.
    I have another question for you as well, because you seem to have quite a number of reports that show that implementing plain packaging will reduce the number of people who are smoking. You talked about the France situation. I did see the Minister for Solidarity and Health had come out and said the program was a failure. But you're indicating that's because they didn't take into account the fact that people had lowered their inventories in advance of the implementation. Japan also had Japan Tobacco International stating that the plain packaging had failed and called to end it.
    Could you just summarize the 150 studies and tell us what kinds of reductions they are consistently seeing, and who had a problem, so that we can clear that part up.
    Clearly, it's still early years, Australia being the first. For some of the others it's just been a year or so that it's been in place. The full benefit is going to be over 20 years. Australia had a post-implementation review to conclude that it's been effective. All the evidence, except that funded by the tobacco industry, points in the same direction. It's intuitive. Billboards increase tobacco advertising. The package is a type of advertising. It increases consumption. It increases the impact of health warnings, the reviews that have been done, and supported by the World Health Organization, on and on.


    My next question can go to anyone who's knowledgeable.
    I've heard that when it comes to vaping, and the flavours that are used in vaping, there's a specific concern about an additive called diacetyl that causes popcorn lung. It's a very serious respiratory condition, but I see a lot of myths on the web, and whether it's true or not true...
    Can you give us any information that you have about that condition?
    Yes, there was a case report. First of all, I would like to say the electronic cigarette has been available in Europe for the last 10 years. If there were any harmful results or effects on the lungs, it would appear in our scientific literature.
    If you look back at this report, of course popcorn lung did happen in the industry manufacturing popcorn. We haven't seen much popcorn lung in the cinemas, although they're exposed to diacetyl.
    If you look at this report, it's a very bad report. I don't understand why the editor accepted to publish the thing because they start by talking about hypersensitivity pneumonitis, like farmer's lung, for example, and then they conclude that it is a bronchiolitis obliterans. It's illogical. They didn't have a lung biopsy to document the case. We have to be extremely careful about these sorts of reports, which are very alarming.
    Right. So you think it's really not substantiated at this point?
    No, not at all.
    On the other hand, with the use of electronic cigarettes we've seen that it's easier to control high blood pressure, you reduce the readmission or the exacerbation of COPD, and asthmatic patients have better control. It's been in use for the last 10 years. For these short-term ill effects of the electronic cigarette, it would appear in the literature....
    Now for the carcinogenic effects of electronic cigarettes, the concentrations are far lower than in the tobacco cigarettes. We still face the use of carcinogenic substances. We haven't stopped taking X-rays. We haven't stopped all the silica mines because it can cause silicosis.
    It's a matter of the dose-response relationship. It is very often forgotten that when you're talking about a risk you have to consider the dose-response relationship.
     Very good.
    My last question is for Ms. James. We're talking about the harm reduction we see with the e-cigarettes. I know you mentioned that Health Canada can put that in their regulations, but do you think we should have that in Bill S-5 so there is a well-thought-out message that would be standard for everyone's use?
    Are you asking if Bill S-5 should contain details around putting a message right on the tobacco product itself?
    I'm asking about vaping products. What should we allow in terms of their ability to claim harm reduction?
    The claims around harm reduction should be stipulated by Health Canada. We should not be allowing industry to decide what claims are made. Health Canada is the one to evaluate the evidence and make the messaging that is appropriate for Canadians to interpret.
    Thank you.
    Mr. Davies.
    Thank you.
    I have questions for all of you, but I want to have a quick yes or no from each of you.
    Mr. Oliver certainly articulated my view on this. He said that we want to do everything we can to prevent young people and non-smokers starting to consume nicotine.
    Does this legislation do that? Is it doing everything we can?


    No. It does not, but it should.
    It does in part. It can do more.
    It needs improvement.
    Mr. Collishaw, I want to come back to you. You talked about key changes you would like to see in the legislation. You mentioned expanding the purpose of the bill, expanding the scope of the act. You said you thought we should be imposing new requirements on the tobacco industry.
    Can you please expand on what you would like to see in terms of new requirements on the tobacco industry that are not in the bill?
    With this bill we're going to legalize a new product, and give the opportunity to tobacco companies to sell some other form of nicotine addiction to people, and they are going to claim it's less hazardous. Dr. Ostiguy has presented some evidence that supports that view.
    If that's so, we think steps should be taken to oblige the tobacco industry, at the same time as they are bringing in a new product, to reduce the supply and demand for the very hazardous products, combustible cigarettes, that they're already selling. This comes back to what I said: let's move from a slogan to a plan on less than 5 by 35. If we're going to have less than 5% by 2035, let's have a plan with milestones to be reached, targets to be reached, corrections to be made if they are not, so we do in fact achieve this noble goal that the government has set.
    Thank you.
    Mr. Cunningham, I have a quick question on vaping and on the plain packaging. On the vaping side, you said the government said that vaping should be limited to brand preference only, but the legislation doesn't reflect this.
    Why would that be?
    Perhaps it's just an oversight in drafting. They have made that statement publicly in what they said related to the bill and regulations under the bill. That's part of the review of committees, so that's an opportunity for us to have an amendment.
    We've heard a lot of testimony on this so I don't want to belabour it. If Bill S-5 currently allows lifestyle advertising in bars targeting young non-smokers of the benefits of vaping with things like allowing draws and contests, winning beach vacations, access to invitation-only parties, tickets to concerts or sporting events, if that's allowed that strikes me—I'm no marketing expert—as something that's probably going to cause a lot of non-smokers and young people to start using nicotine. That sounds to me like more of a drafting oversight.
    We think it's an important deficiency and it can be remedied through an amendment to ban all lifestyle advertising, period.
    Do all of you agree with that?
    A voice: Yes.
    Mr. Don Davies: Don't worry, I'm coming back to Mr. Ostiguy on this.
    On the plain packaging, I'm going to be a little harsh on this. I view tobacco products to be an addictive carcinogen. They have no redeeming features whatsoever. We're the health committee, so I think we should be doing everything we can to stamp them out.
    I think the tobacco industry is like a corporate zombie. It just keeps coming and coming if we don't close every single loophole. That's the experience, I think, Australia has.
    I'm curious on the plain packaging. Is there strong enough language? I'll put it this way. The federal government, in terms of the brand names on the package...“the proposed regulations concerning plain packaging, Health Canada did not include the option of further regulating brand names beyond limiting the number of words they [can] contain.”
    Is that strong enough, or are we going to see “Smoking Makes You Taller, Richer, Better Looking, and Sexier Inc.”
     We're certainly concerned about that, given what has already happened in Australia, where they have these extended names to try to have these lifestyle or positive images created. I think that when Health Canada does the regulations, they should ensure they clamp down on that to avoid this type of messaging.
    Ms. James, you showed us what I consider to be some of the worst marketing. This is marketing to young women. It looks like a cosmetic. This is the type of cigarette they market that says “vogue” on it. Does Bill S-5 ban these slim cigarettes?
    The proposed regulations will, but an amendment to make sure that happens in Bill S-5 would be beneficial.


    Do you have any advice to give us in terms of the size of packaging? Should there be a standard size and feel of packaging as opposed to these different—
    That's a great question.
    These packs are little. They fit in your clutch, in your purse, in your pocket. Youth like them.
     Young Canadians hate this pack. It's cumbersome, bulky. The warning is big; it's in your face.
    This is what the industry wants, a flip-top, because it's still quite small and cute.
    If we can move ahead with anything, it's slide-and-shell. It's a big, clunky pack that has large warnings and isn't easy to carry around.
    Thank you.
    Finally, Dr. Ostiguy, you said that e-cigarettes shouldn't be more restrictive to access than cigarettes. I'm going to flip that around. Do you agree that it should be as restrictive, though?
    What do you mean? Do you mean the sale of them?
    Yes. In terms of the marketing, the promotion, the labelling, the packaging, would you agree that all those things should be as restrictive for e-cigarettes as for tobacco products generally?
    I do agree with Bill S-5 that the e-cigarette doesn't need to be advertised. I see the e-cigarette as a tool for the addicted smoker to stop smoking.
     For example, with the Quebec law at the moment, it's impossible for the owner of, let's say, a vape shop to teach his customers how to use electronic cigarettes. It is not that easy to use them properly. They're not even allowed to show the stuff they can sell in their window.
    I have an example of a vape shop where they have a blind on their window. They aren't able to advertise the stuff they could sell to an addicted tobacco smoker. Next door is a sex shop with all the stuff in the window, and the door is open. So let's be logical sometimes in our legislation.
    The point I'm concerned with at the moment is the fact that the population is under the impression that the electronic cigarette is as harmful as the tobacco cigarette. It doesn't need to be advertised, but at least let the owner of a vape shop teach customers how to use it properly, and allow them to tell them that it is less harmful.
    I've seen lots of references to the Australian experience, but I wish people would pay some attention to the British experience—the document issued by the Royal College of Physicians in London, the fourth document published by Public Health England.
    In the last report, Public Health England even suggests having vape shops in hospitals. They are suggesting that the national health scheme pay for the electronic cigarette for the addicted smoker. We know very well that the greatest proportion of smokers are people who are poorer and less educated.
    Thank you very much. l have to cut you off there.
    Ms. Sidhu, you have seven minutes.
    Thank you all for being here. This is an important study as we work to keep Canadians healthy.
    My question is to Dr. Ostiguy.
    You have said that e-cigarettes are a good alternative to encourage people to get away from tobacco use, but many e-cigarettes come with flavours like cotton candy, watermelon, and black cherry. What is the purpose of these flavours? When they come with these flavours, are they not designed to get more people smoking—more young people?
     The British experience tells us that electronic cigarettes are used by less than 1% of people who have never smoked. When we look at the statistics about young people taking up vaping, we have to be very careful about the questionnaire. It's not because you used electronic cigarettes once in the past month that you've adopted them.
    It's better to look at the way the British people have made up their questionnaire. They ask, “Have you ever used...?”, but also, “Do you routinely use this?” “Do you use it on a weekly basis?” “Have you bought an electronic cigarette for your own use?” The British experience says that fewer than 1% of youngsters or young adults who take up electronic cigarettes have never smoked; most have already started using tobacco cigarettes.
    In all these questionnaires, they don't ask, “Have you used an electronic cigarette with nicotine or without nicotine?” They also don't ask, “If you have ever smoked tobacco cigarettes, have you tried an electronic cigarette in the past?” In the proportion of the youngsters who have tried electronic cigarettes, you have the ones who have already used tobacco cigarettes.
    We have, then, to be extremely careful about the way these questionnaires are made.


    Lesley, can you speak to some of the concerns that suggest e-cigarettes used by young people might lead to tobacco use?
    Do you not think they can attract youth?
    There are a lot of questions around whether e-cigarettes are a gateway to tobacco use. There are Canadian studies that say that longitudinally, when we look at a cohort of young Canadians, those who try e-cigarettes are more likely to initiate tobacco use a year later. There's still a lot that needs to be known, though.
    What we are concerned about is whether, when nicotine becomes legal in e-cigarettes, these youth will now have a nicotine addiction. Will this even further increase rates that we're already seeing grow year by year?
    In relation to flavours, we want to make sure there isn't a wide range of flavours, such as cotton candy, Hello Kitty, cherry, or whatever it might be. We want things that are appealing to adult smokers, but not youth; we want to make sure that youth in general don't see marketing of these cigarettes, because it might lead to tobacco use later on.
    Thank you.
    My next question is to the Cancer Society. Many Canadians still smoke tobacco, and many are becoming regular smokers each year. What can we do to reduce the number of new smokers? How can smokers kick the addiction?
    We need a comprehensive strategy. Many things work in combination. Plain packaging is part of it; banning flavoured tobacco is part of it. There's a great opportunity for Minister Petitpas Taylor, with the renewal of the federal tobacco control strategy. The current one expires in March 2019.
    There have been consultations. The minister has been working on a new strategy, and that is a great opportunity to restore some initiatives that we previously had for cessation, youth prevention, enforcement, mass media campaigns, policy development—all of the different elements we can have that can really make a difference.
    Dr. Collishaw, what do you think about this? How can we reduce the number of Canadians impacted by the harm of tobacco smoking?
    We've made good progress in recent years. Most of the progress we've made against tobacco in recent years has been due to a lower rate of uptake among youth. I would like to see that trend continue.
    The challenge we face with this bill is. I'm afraid that it may open the door for young people to pick up this product and become addicted to nicotine. We'd like to prevent that before it happens and carry on with other measures to strengthen our comprehensive tobacco control measures so that we can continue to lower tobacco use among our youth.


     Just to add to that, a potential approach would be the polluter pays principle, whereby the tobacco industry is required to reimburse Health Canada for the cost of the tobacco strategy. Right now, Health Canada's $38-million budget works out to about $1.04 per capita. In the United States, it's about $3.60, more than three times the amount. Exchange rates vary.
    In the United States, the Food and Drug Administration recovers the entire cost of its annual tobacco budget from the tobacco industry, based on market share. That's something we could do in Canada, to have as much impact as possible, to reduce youth use, and to enhance cessation.
    I should add that France has also adopted the polluter pays principle. They have a special tax on tobacco suppliers, and all of the money goes to fund tobacco control.
    That completes our seven-minute round. We'll go to five-minute rounds.
    We'll start with Mr. Webber.
    Thank you all for being here today.
    I have a silly question to start with. I'm not a smoker. I don't hang out with people who smoke. What is the difference between an e-cigarette and vaping?
    Maybe Lesley could answer.
    It's the same thing. Electronic cigarette, e-cigarette, vaping: it's all the same terminology.
    All right. You were bouncing back and forth from vaping to e-cigarettes—
    Yes, it's confusing. I'm sorry.
    They're the same. All right.
    Here is a question to Dr. Ostiguy. Let's say I am a smoker, and I come to your smoking cessation clinic and tell you that I really want to quit, that I've had it with smoking. You said in your presentation that it takes more than willpower. I have the willpower, but obviously I need more.
    What would you suggest I do: go with a nicotine patch or go with an e-cigarette? What do you tell your patients?
    The first thing is to find out what you have tried in the past. Most people have tried many different things in the past. We have to build on that experience.
    Now, we have to also assess how addicted you are. Are you a hard-core smoker or a light smoker? If you're a hard-core smoker, we have to assess this. It could be assessed by the number of cigarettes you smoke, and of course, in a clinic such as ours we measure the nicotine level in the blood, which is a much better way of assessing the amount of dependence a person has.
    Then we discuss with the patient what they would like to start with. Usually we would start with pharmacotherapy approved by Health Canada, nicotine replacement therapy. It's only recently that we have seen advertising recommending combined nicotine replacement therapy. We've been using this for 15 years. The patch does provide a level of nicotine, which is very low and doesn't give the kick that a smoker gets from a cigarette. You need a way of delivering nicotine that will go to your brain much faster than by any of these devices, so we have to use combined therapy.
    I had a patient with severe emphysema. He was unable to climb the six stairs coming up to the clinic. He was admitted two or three times a year for COPD exacerbation. He was using his action plan every month. We gave him Champix, we gave him patches, we gave him nicotine gums, we gave him bupropion, and all of them were failures.
    He decided to buy an electronic cigarette. After one year, his concentration of nicotine in the electronic cigarette was down to three milligrams per ml. He was not admitted for any COPD exacerbation and he didn't use his action plan, except for once during that winter, and since he had a construction business, he converted a room in his house into a gym.
    I could tell you success stories like this time and time again, but there's not one way of approaching; this is the sort of thing we have to discuss with the patient. Unfortunately, we don't have what they have in Europe. Each hospital should have a good smoking cessation clinic that can address these cases of hard-core, addicted smokers.,


     You're suggesting that we need a product out there that can provide more nicotine in a patch, for example. It's not enough, what's out there now.
    I presume that you're aware of this study coming from the Mayo Clinic saying—and the government pays for that—that people buying nicotine patches at the pharmacy without any counselling had the success rate of quitting smoking lower than the ones who quit by themselves cold turkey. You literally need coaching and counselling.
    Thank you, Doctor.
    Mr. Cunningham, on your graph that you gave us all here, a way to decrease smoking in Australia, can you clarify again to what you attribute the success in Australia? What did they do there?
    There are a number of factors that would have contributed to declines. It's not just plain packaging. There are other measures in place as well. The Australian authority, the health department, concludes that plain packaging was one of the factors that has contributed to the decline in prevalence.
    We're going to go to Mr. Ayoub.


    Thank you, Mr. Chair.
    My thanks to the witnesses for being here.
    It is always very interesting, of course, and it is difficult to satisfy everyone and to come up with a solution that addresses all the problems. I was wondering about the stores that sell vaping products.
    Like my colleague opposite, Mr. Webber, I do not smoke. So I do not go to those stores to buy cigarettes. Do they sell nicotine patches there? Do they sell products to help people stop smoking? Having said that, I doubt it.
     You talked about support for people who want to stop smoking. If they do not have medical support, or at least some professional support, they have significantly fewer chances of success. The problem with e-cigarettes with nicotine is that they are generally and easily accessible on shelves. If e-cigarettes were sold in pharmacies, by health professionals who could follow up with those who buy them, then it would be possible to see the evolution of the treatment and, subsequently, to improve the situation.
    Mr. Ostiguy, what do you think about that?
    That was suggested. I have given lectures to pharmacists myself, but the message did not get through.
    Of course, pharmacists could play a very important role in tobacco control. They already do so in pharmacotherapy, which is approved by Health Canada. They could do it for e-cigarettes.
    You say that the message did not get through; what do you mean by that? Is there a lack of will to embark on this field?
    Yes. They showed no interest in engaging in this sort of activity.
    Mr. Collishaw, what do you think?
    I'd like to make an additional comment.
    Those products are on the market. Since 2009, Health Canada has said that those products are not permitted without the submission of a proposal that would result in approved therapeutic products. No one has submitted such a document. Even though those products are less dangerous than cigarettes, they do not reach the “therapeutic” threshold according to the Health Canada standard. If we made the products legal through Bill S-5, we would sort of create a third route between illegal products and therapeutic products approved by Health Canada.


    I will set aside the technical aspect of nicotine.
     On the economic front, we are talking about contraband and prices. If we draw a parallel with the legalization of marijuana, there is the whole issue with the price of the product. That's what makes contraband come into play or not. In this sense, it becomes advantageous for a regular smoker, who spends several thousand dollars a year anyway, to use contraband. If the price of cigarettes goes higher and higher, it is a damper for a certain segment of the population. However, for people who are regular consumers, it is advantageous to get contraband and encourage that market.
    Have you noticed it in your studies and in terms of consumption?
    Price increases are the most effective way to reduce consumption, especially for teenagers, who do not have a lot of money for that.
    In Canada, there is smuggling, but it is more prevalent in Ontario and Quebec, where taxation is lower. In the west and the Atlantic, contraband is much less significant, not necessarily because of high taxes. Illegal factories and proximity to urban centres, such as Toronto, Montreal and various parts of southern Ontario, encourage smuggling.
    There are measures we could use to fight smuggling. We have recommendations for Ontario and the federal government. We could do it at the same time.


     The time is up.
    Ms. Kusie.
    Thank you very much, Mr. Chair.
    Dr. Ostiguy, what warnings or cautions do you believe should be labelled on nicotine vaping products? You indicate that you feel they must be regulated but that availability must not be made more difficult than for buying tobacco cigarettes. What cautions or warnings would you advocate for on vaping packaging?
    It should be said that nicotine could become addictive; this is something to be careful about. This is about the only concern I would have about the electronic cigarette.
    Again, I wish people would pay more attention to the studies coming from England and Europe saying that among those who have never smoked, it's very unusual for youngsters to take up electronic cigarettes. In electronic cigarettes, the addictiveness of the nicotine is not as strong as with tobacco cigarettes, because although nicotine is addictive, with the tobacco cigarette you have all the constituents of the tobacco that make it more addictive—the pH, the flavour, the chemical additives, such as menthol and that sort of thing. Yes, nicotine could be addictive; coffee is also addictive. However, with electronic cigarettes, the addictiveness is less than with tobacco cigarettes.
    In my experience, when the heavy smokers, the addicted smokers, decide to buy an electronic cigarette, very often people want them to stop from one day to the next. That's not the way. They go down; they start with 18 milligrams and then they go to 15, 12, 9, 6, and then to zero. We have to be patient. It might take a year or a year and a half to do so, but we have to be patient and give proper follow-up and counselling.
    Thank you.
    Mr. Chair, I'd like to go on the record as saying that I've never tried smoking a single cigarette. When I was 12, my father offered me $100 if I made it to the age of 18 without smoking a cigarette. It worked. I plan on doing the same with my family.
    Dr. Ostiguy, I have another question. You mentioned that it has sometimes worked that your patients moved from cigarette smoking to e-cigarettes. Have you seen or could you perceive a trend in young people whereby they move from e-cigarettes to smoking? Do you see this as a possibility, or is there an increased risk or threat of it?
    I don't see it in our clientele. Of course, we're dealing with an adult clientele.
    An excellent review was issued last week in the most recent document from Public Health England about the gateway effect that people were talking about. It's very difficult to make a good, sound, scientific interpretation of all this data, because it's been studied in different ways using different questionnaires, but the British experience is firm about saying that the electronic cigarette is not adopted by those who have never smoked. It's fewer than 1%.


     Ms. James, in your opinion, why do people start smoking? Do you think it is a coping method? Do you think it's to be cool? To me, this is just so much the crux of this. Why in your opinion do people start smoking?
    People start smoking for a variety of reasons, and the marketing of tobacco products is definitely one of the reasons. Role modelling also plays a big part in this.
    We see high levels of tobacco use among indigenous populations in Canada. It's quite hard for youth not to start smoking when they're surrounded by this in their environment.
    Any strategy that aims to reduce smoking and prevent uptake needs to address youth use and indigenous use, and create opportunities where smoking cessation products are more affordable and accessible than tobacco products.
    It sounds likely cultural.
    Mr. Cunningham, in 25 seconds, would you like to weigh in please?
    There are many factors. Sometimes it because it's available. Sometimes it's because of the low price or attractive flavours. For a certain segment of youth, it's a very positive product. It has a positive image that marketing creates, and that's why we need plain packaging.
    Dr. Ostiguy, in 10 seconds, why do your patients start smoking?
    Have you known of a teenager who doesn't want to try something that is a bit hard and a bit dangerous? Whether it's alcohol, driving, sex, or anything, it's part of the teenager mentality.
    I'll keep my hundred bucks.
    Thank you, Dr. Ostiguy.
    Thanks very much.
    Now we go to Mr. McKinnon, for five minutes.
    Dr. Ostiguy, you said—and I think everyone agrees—that vaping is safer than tobacco, that vaping is safer than cigarettes. That seems plausible to me. I can think of a number of reasons why that might be so.
    I'm wondering about the body of research behind that. What do we have? Vaping has only been around, at least on the market, for about 10 years. Do we have really solid evidence that backs it up?
    Dr. Ostiguy, we'll start with you.
    For example, in Great Britain, three million people stopped smoking with the electronic cigarette. Farsalinos in Europe with a Euromonitor study said that they estimate that 27 million people stopped smoking with the electronic cigarette.
    As I said before, if there were some ill effects of the electronic cigarette on the cardiovascular system or on the pulmonary system, they would have appeared in our scientific literature, and they haven't. I don't need a placebo-controlled, double-blind study to tell me that I am less likely to kill somebody if I drive 20 kilometres per hour in downtown Ottawa than if I drive 120 kilometres per hour.
    Knowing that the carcinogenic substances, which could be a concern, are in such a low concentration in the vape of the electronic cigarette, I think that this is a risk....
    I'm not saying that it is completely harmless. The Royal College of Physicians in London doesn't say it's 100% proven safe. They say it's 95% less harmful than the tobacco cigarette. Most of the damage from tobacco comes from combustion, and if you do have a product that doesn't have combustion, then you eliminate many of the ill effects of tobacco.
    Go ahead, Dr. Collishaw.
     I don't think anyone here doubts that vaping is going to be less hazardous than smoking, certainly for smokers. The problem comes with the potential public health effects. What happens if these products are widely available, and people who never smoked start picking them up or ex-smokers start picking them up? Then they're going to become addicted, and some of them are going to move on to combustible cigarettes, and the whole epidemic is perpetuated. Those are the problems we're trying to avoid while maximizing the benefits that Dr. Ostiguy has referred to, whereby there is a potential for smokers who are unable to quit to at least have a somewhat less hazardous experience with satisfying their nicotine addiction. Once again, it's a question of balance. How can we get the benefits that are going to come from legalizing this product while guarding against the potential for harm?
    I would further comment on what Dr. Ostiguy said earlier about how there hadn't been much problem in European countries with young people picking up these products. It should be noted that in most of these countries, advertising for these products is not allowed. Even in England, where some advertising is allowed and there's strong advocacy for the use of these products, the advertising that is allowed is much less than would be allowed under Bill S-5. Where there is a serious problem with young people picking up these e-cigarettes in large numbers is in the United States, where advertising for them is unrestricted. That is a situation we do not want to get into in Canada.


    To play devil's advocate, if vaping is 95% safer than smoking, there are very much fewer health consequences of it. Nicotine is certainly addictive, but so is caffeine—and I certainly have that problem myself—but it's not a life-altering thing. Why do we care?
    The 95% statistic is based on qualitative opinions. We can't quantify and say e-cigarettes are 95% less harmful than combustible tobacco. I caution against using that number and widely circulating it. We know e-cigarettes are less harmful, and Heart and Stroke believes that, but we don't know how much less harmful, and we won't know for some time. It will take decades for us to figure out what this means for long-term health consequences. We do know that nicotine is detrimental to youth development. We need to keep it out of the hands of young people. That's why marketing needs to be restricted.
    Thank you very much.
    Now we go to Mr. Davies for three minutes.
    Thank you.
    Ms. James, I'm interested in exploring the difference between vaping and heat-not-burn. I don't think we've had very much testimony on the heat-not-burn products, which—from everything I've heard—the tobacco companies are at the gate waiting to come in and fully explore.
    What are the health consequences or your thoughts on the heat-not-burn products?
    Heat-not-burn products are very new, and they're being marketed as a reduced harm modality. There is no evidence to suggest that being the case. On the spectrum of harm, we see e-cigarettes on the one side, combustible tobacco on the other, and heat-not-burn somewhere along that line, but we don't know where they are. We shouldn't be recommending Canadians try these products because it still is tobacco, and that's harmful.
    Okay. I'm going to stick with you if I can.
    I'm a little confused about nicotine's long-term health effects. I don't want to put words in Dr. Ostiguy's mouth, but I almost had the impression've mentioned its effect on rising blood pressure and heart rates and other—
    Blood clots.
    Blood clot risk.
    Again, not to be unfair to Dr. Ostiguy, I heard him indicate that nicotine is not very harmful to our health. What do we know about the long-term health impacts of nicotine?
     I'm not a clinician, so I'll let the physicians speak to the long-term impact of nicotine, but we know that the U.S. surgeon general has reported there's an increased heart rate and blood pressure and a possibility of blood clots, and we know that over a long term, nicotine use among youth is detrimental to development of their brains.
    Mr. Ostiguy, I'll give you a chance to tell me, can I consume nicotine every day for the rest of my life with no health worries?


    I don't think you should be very concerned about this. Your body adapts very rapidly to nicotine. Of course, after you smoke a cigarette, you might have a very temporary acceleration of your heart rate, but it comes back to its usual rate. It doesn't have any long-term effects.
    I'm not promoting the advertisement of nicotine or any nicotine-delivery device. I agree that nicotine in any form should not be available to people under the age of 18. I quite agree with that, but I don't think we should exaggerate the harmful effects of nicotine, except that it's addictive.
    Mind you, the smokers smoke.... There's no better way to control your mood than to have a cigarette. What were they giving to the soldiers at the front during the war? They were not giving them chocolate; they were giving them cigarettes.
    Time's up.
    We have some time left, however, so I'm going to propose that we have a round one again, with four-minute questions. That will allow us the five minutes to get to Question Period, but each side will have an extra question, based on our first round.
    I'm going to hold you to four minutes, then, and we're going to start with Dr. Eyolfson.
    Dr. Ostiguy, you were talking about some data in England, particularly regarding vaping and young people, and you said it's very unusual for young people to start vaping who have never smoked.
    An article in the Canadian Medical Association Journal in 2015 reported that people aged 15 to 19 actually are twice as likely to have tried vaping as smoking. They found that 20% of people aged 15 to 19 had tried vaping, whereas 11% of the same cohort had tried smoking.
    Would it be fair to say, at least, that the studies you're referring to out of England would not be applicable to the Canadian experience?
     I think you have to look at the way the questions were asked. “Have you ever tried electronic cigarettes in the last week?”; “Have you ever tried electronic cigarettes over the last month?”
    Well, it asked whether they have “ever”.... I'll finish that, but that was the question, “Have you ever tried...?”, and they were twice as likely. That was the finding.
    Another question has to do with whether there's relative harm, and as you said, Ms. James, qualitative as opposed to quantitative relative harm. I have another Canadian Medical Association Journal article, and this is from October 2017. It talks about electronic cigarette use and smoking initiation among youth.
     Now, I'll be the first to say, it's correlation—we have not proven cause and effect—but this says very clearly, on a very large longitudinal study, that young people who start vaping are significantly more likely to take up the smoking of cigarettes.
    Is this not in itself a potentially harmful and dangerous product?
    I'd just like a yes or no from the panel.
    Yes, it is.
    Yes, but with some limitations.
    Okay, what are the limitations, very quickly, sir?
    It has to be a long-term study—
    But we do know that when a person starts as a young person, they are very likely to be addicted. We know that; it has been known for decades. Would you not agree?
    Well, you don't become addicted after 10 or 15 cigarettes—
    No, but the more likely you are to smoke, the more likely you are to be addicted. I think that would be clear and has been clear for decades.
    I think, again, it has to be.... I wish you would go to the last report of Public Health England, issued last week. They review all the studies: the American studies that you're talking about, the Canadian studies—
    These are Canadian studies, fairly recent large Canadian studies.
     Yes. They discuss all this, and it's very difficult to analyze this data because of the way the questions were asked. You have to be very careful about saying that it's—
    We can only use the data we have.
    Yes, but all the data all over the world.


    Thank you very much.
    Ms. Gladu.
    Thank you, Chair.
    We all know that smoking is not good for you, so it's sad and troubling that the government is legalizing the smoking form of marijuana. I know there are some people who vape cannabis. I don't really see that this is covered, either in the cannabis legislation or in the vaping legislation specifically. Would you recommend that we include it, and if so, where?
    Through a combination of Bill C-45 and this bill, it will not be possible to consume cannabis wherever smoking is banned in federal workplaces—banks, broadcasting, the RCMP, or the federal government.
    Vaping devices can be used to consume cannabis and other substances, so that's a question if widespread advertising of these devices is to be allowed. It's much more open than in the cannabis act. The government should not intend to undermine the restrictions it has in the cannabis act.
    I would agree, and with the legalization of marijuana, the Heart and Stroke supports the low-risk user guidelines. They are detailed in that they are developed by the Canadian Medical Association and the Centre for Addiction and Mental Health around how Canadians can reduce the risk if they choose to use cannabis. Within that, there are details about vaping marijuana.
    Very good.
    I have another myth-busting item. I hear quite often that folks who are either diabetic or in some cases obese and trying to get away from that are starting to vape using the cherry-flavoured kind of thing we're talking about.
    Have you heard about this at all? Is it a myth? Is it real?
    I would expect it's anecdotal. I've seen no indication that this is widespread, or any level of volume of activity apart from anecdotal.
    Polosa in Italy has published a paper about this, and up to now vaping doesn't seem to help people lose weight. This is about the only study I'm aware of.
    One of the questions I have has to do with the nicotine concentration that we're going to allow. Do you think that we should be taking our signal from...? The U.S. is trying to reduce the amount of nicotine they're going to allow in products. Should we start with a reduced concentration of nicotine allowed for vaping products?
    With respect to vaping products, the government has a consultation paper. They have regulatory authority. There should be some upper limit in nicotine products as to how much nicotine would be allowed. There's a different issue with respect to cigarettes. A proposal to take nicotine out of cigarettes is simply not viable in Canada. People smoke for the nicotine. It would functionally be the same as banning cigarettes, and in Canada we can't ban cigarettes.
    I have another question about age. The bill we have here defines young persons as being under 18, and there are some provinces that don't allow tobacco products for those under 19.
    What should we do in the bill? Should we go to the highest denominator and call it 19? Should we say it's whatever the age in the province is? What would you recommend?
    Keeping it out of the hands of young Canadians is vastly important, so if there's an opportunity to increase the age to 19, that would be beneficial.
    One option is that there could be a regulatory authority to increase the age in the future.
    I'll add that in Europe the maximum concentration of nicotine in the e-liquid is 20 milligrams per millilitre, and this has been adopted by most of the countries that have adopted the tobacco coalition. It's a reasonable target.
    Thank you.
    Mr. Davies, you have four minutes.
    Mr. Collishaw, I wanted to get your opinion on the heat-not-burn product.
    Regrettably, these are already on the market in Canada. We have no way of keeping recreational nicotine products off the market. In the United States they're currently under review in premarket approval, and much ink has been spilled in the United States in this premarket approval process. A scientific committee has recommended to the FDA that they not be allowed to make health claims. We'll see what happens.
    In Canada what concerns me is even though all tobacco products are covered under the current Tobacco Act, there isn't a proper set of regulations for heat-not-burn products, and there is an opportunity to at least partially correct this situation with some further amendments to Bill S-5. I don't want to go into a lot of detail here since there isn't a lot of time, but I can show all of you some proposals that I have in that regard later on.


     Mr. Cunningham, Mr. James, or Mr. Ostiguy, whoever wants to answer this, I remember my dad telling me that when he started smoking in the fifties people kind of knew it was bad, and it was frowned upon, but they didn't know that it caused cancer. In my lifetime, I've seen the development of tobacco products lead to to a light cigarette, a slim cigarette, and lower tar. There has been a gradual movement of the industry to adjust and to try to convince people that smoking is less harmful.
    Here, we're standing on the cusp of a new product. We have vaping and we have heat-not-burn products. I'm not sure what else is ingested when you suck in the liquid nicotine. I'd be curious to know if there are any other chemicals. Do we have any concern that we're not going to be having a conversation 20 years from now, like my dad did with me in the fifties, when we'll be saying, gee, we wish we knew back in 2018 that there were more harmful effects from vaping or heat-not-burn products? Or are we sure at this point that this is not the case?
     Over the decades, the experience over time has been that products turn out to be much more harmful than we initially thought they were. Also, some years ago, there were some predecessors to these heated products launched in the United States. The tobacco companies didn't disclose all their research. They cherry-picked a bit what research they disclosed and, of course, we have that concern today.
    Ms. James, do you have a comment?
    For the reason you mention, I think we need to be very cautious about who is using e-cigarettes. As I've said before, the only group that should see marketing of e-cigarettes are current tobacco smokers. Other than that, there's no benefit to anyone trying e-cigarettes. We need to make sure that they stay out of the hands of young people and that non-smokers aren't persuaded to try them.
    Yes. We have had a lot of talk in this committee about the cannabis legislation, etc., over so-called gateway drugs, and there's a great debate over whether cannabis is or not. Is there any concern that people who start vaping could eventually migrate over to smoking cigarettes? Is that a concern? We're talking about it the other way. We're talking about moving smokers of cigarettes over to vaping as a bit of a harm reduction tool, but I'm wondering if there is any research or concern about it going the other way.
     Let's say this legislation goes forward and my children are in their twenties and thirties, they're in a bar, and they see this beautiful vaping advertising. They start vaping. Is there any concern they might eventually move to cigarettes?
    There definitely is a concern, because there will be nicotine in these products once Bill S-5 is passed, and who is to know what will happen in terms of addiction from choosing to use either an e-cigarette or a tobacco product? From research that came out and was published by CMHA, we do know that youth who use e-cigarettes are more likely to be using tobacco products a year later.
    Your time is up.
    Mr. Oliver, you have four minutes.
    Thank you once again. I think this is the last round of questioning you'll have to endure from us.
    I've heard from all of you that you think there should be greater restrictions on advertising of vaping. Both the Cancer Society and Heart and Stroke, I think, have come up with some advice on that.
     There were four areas where you thought there should be vaping product amendments: one, limit vapour product advertising to be only information advertising or brand preference advertising; two, remove the provision that allows lifestyle advertising in bars and in publications sent to adults; three, restrict permitted vaping product incentive promotions to speciality vaping product retail stores, which is similar, actually, to cannabis; and, four, strengthen restrictions on the location of permitted incentive promotions to match the Tobacco Act restrictions.
    To the Cancer Society, is there any else that you want to add to those four?
    To the other three, do you agree with those restrictions on vaping advertising? Is there anything else you would like to see our committee add to reduce the amount of advertising possible for vaping products?


    I think you've summarized the key categories of amendments for the act.
    Heart and Stroke fully endorses the Canadian Cancer Society's recommendations and the rationale for them.
    Is there anything Heart and Stroke would add to those restrictions?
    In terms of correcting the problems we see with advertising, we also support this position. However, as I mentioned in my remarks, we have other concerns about how we should further restrict and diminish use of combustible cigarettes, but that's another topic.
     Dr. Ostiguy.
    I agree with the ban on advertising. The popularity of this gadget never came from the health professionals of the medical society. It has come from the population. It doesn't need to be advertised. They'll go to it. The only thing is not to create barriers for the highly addicted smokers to be allowed to get the electronic cigarettes if they want to stop smoking.
    To be fair, recommendations from the Cancer Society also had a number around smoking. I wanted to focus because you're all very strong that vaping manufacturers shouldn't be allowed to advertise at levels beyond tobacco.
    That's the end of my questions.
    Thank you very much.
    I want to thank you all for your presentations.
    I want to go back to the introductions. Ms. James had a line that really caught my attention. I checked to see if it was accurate, and apparently it is. Tobacco use in Canada remains the leading risk of premature death in Canada, killing 45,000 people each year.
    I didn't think that number could be right but it looks as if it's the one that's most often used. Then I compared the automobile fatalities: 1,858 per year. Based on that number, 20 times more people died from tobacco use than in cars. I think of all the things government has imposed on the automobile industry to reduce car fatalities: headlights on, back-up cameras, seat belts, airbags, and so on. The government has required the companies to change their product to make it safer, then they've tested it.
    You've made me do a lot of thinking.
     I'm so glad you didn't get into all those books, Mr. Cunningham. I was looking at them, and I was scared during the whole meeting.
    You've been great presenters and you've helped us a lot.
    Thanks very much.
     The meeting is adjourned.
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